FOCUS CHARTING SAMPLE CHARTING

FOCUS CHARTING is a method for organizing health information in the individual's record. It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action.

FOCUS
a key word or diagnostic category

from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission

 a sign or symptom of (possible)

importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy an acute change in an individual's condition, i.e. respiratory distress, seizure, fever, discomfort

 a significant event in an individual's

care, i.e. begin treatment regimen (oxygen), change in diet, catheterization

a key word or phrase indicating

compliance with a standard of care or agency policy, i.e. self medication teaching plan,

NOTE:
Data: Subjective and/or objective

information supporting the stated focus or describing observations at the time of significant events. Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated. Response: Description of individual's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment.

SAMPLE FOCUS CHARTING

March 8, 2012 6:00am 2:00 pm shift

DATE /TIME

FOCUS

DAR

3/08/12 D: Sumasakit and 10:00 Chest dibdib ko.Midclavicular am pain line pain of 6 on scale of 10 A: Isordil 5 mg.SL given 12:00 pm Chest R: Resting in bed. pain Nabawasan na ang sakit ng dibdib ko.

RESPONSE IS USED ALONE TO INDICATE A CARE OF PLAN GOAL HAS BEEN ACCOMPLISHED
DATE /TIME FOCUS DAR

3/8/12 1 pm

Health R: Patient Teachi demonstrates ability to ng change his own abdominal dressing using aseptic technique

March 8, 2012 2:00pm 10:00 pm shift

is to document assessment finding and there is no flowsheet/ checklist for that purpose DATE /TIME FOCUS DAR

3/8/12 Post 2:20 pm transfe r Assess ment

D: Received from RR via stretcher, awake and alert, vital signs stable, Intravenous fluid of D5LR @ 500 cc level @ right foerarm patent and infusing well.

DATE /TIME

FOCUS

DAR

3/8/12 Post 2:20 pm transfe r Assess ment

Foley catheter in place with clear yellow urine, dressing on Right Lower Quadrant is dry and intact, moving all extremities voluntarily. Minimal incisional pain at this time with pain scale of 2/10

ACTION AND RESPONSE

are repeated without

additional data to show the sequence of decision making based on evaluating patient response to the initial intervention

DATE /TIME

FOCUS

DAR

3/8/12 Nause D: Parang puno 9:00 pm a angtiyan ko at nasusuka ako. Abdomen round and soft, gastrostomy bag at body level , rare bowel sounds A: Gastrostomy bag lowered R: Di na ako

DATE /TIME

FOCUS

DAR
Monitor abdominal status. Monitored how long bag is tolerated at body level. Patient instructed to call nurse when he is uncomfortable R: I understand

3/8/12 Nause D: Kept gastrostomy bag 9:30 pm a at body level.

Begin the note w/ ACTION when the pts interaction begins w/ intervention or when inc. DATA would be unnecessary repetition

DATE /TIME

FOCUS

DAR

3/8/12 Health A: Patient instructed on 9:45 teachin actions and side effects pm g of digoxin. Digoxin Given digoxin card. Discussed when he would call physician about medicine. R: Return demonstration of radial pulse. 10:00 Endorsed sleeping on

Sample Focus Charting

DATE /TIME

FOCUS NEED (COMFOR T; RELIEF OF PAIN)

DAR
D: Complaining of continuous, sharp pain in mid- abdominal incisional area. Crying. I need something for pain now! States pain is 9 on a scale of 10. A: Medicated with Demerol 75 mg. IM Left Upper Outer

3/8/12 6:00 am

DATE /TIME

FOCUS NEED (COMFOR T; RELIEF OF PAIN)

DAR
D: Complaining of continuous, sharp pain in mid- abdominal incisional area. Crying. I need something for pain now! States pain is 9 on a scale of 10. A: Medicated with Demerol 75 mg. IM Left Upper Outer

3/8/12 6:00 am

DATE /TIME

FOCUS
NEED (COMFOR T; RELIEF OF PAIN)

DAR
Repositioned on right side with pillow to help splint wound. R: Patient stated pain was much better 30 minutes later and rated it 3 on a scale of 30.

3/8/12 6:00 am

General Survey

Appearance of the patient,

condition- when seeing the patient Any IVF or Medications attaches to the arms of the patient Current Vital Signs of the Patient

DATE /TIME

FOCUS

DAR
R. Approached sitting on bed, awake,
responsive, coherent with ease in respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @

3/8/12 6:00 am